Pharmacologic Treatments

2 Cognitive Behavioural Therapy (CBT) Psychosocial Interventions

3  Medication Intro › Provide rationale, expectations & education › Explain how medication works › Warn of potential side effects › Health Canada Warnings  Suicidal thoughts and behaviors › Provide timeline  Titration  Treatment response Medication Intro

Pharmacological Treatment of Adolescent Depression/Anxiety Disorder Children & Adolescents

5 Do not use to treat mild symptoms or for “usual” stress Do not rush into medication subscribing!

6  Not all anxiety or depressive disorders require medication  Recommended first line treatment › Cognitive Behavioral Therapy Approach e.g. CBIS › Selective serotonin reuptake inhibitors (SSRI)  Fluoxetine or Sertraline › If not tolerable refer child to mental health services  Medication should not be used alone › Anxiety and mood management strategies Antidepressants

7 Combine with: CBT Wellness Activities Support Education Self Help Strategies

8  Minimal evidence in < 7 yrs  SSRI’s: › Fluoxetine › Sertraline  Do not use alone  Suicidal ideation & self harm behavior Antidepressants in Childhood

9 1.Do no harm 2.Ensure diagnostic criteria are met 3.Check for other psychiatric symptoms/stressors 4.Check for other psychiatric symptoms/stressors 5.Check for agitation, panic or impulsivity 6.Check for family history of mania or bipolar 7.Measure patients current somatic symptoms before beginning treatment › Restlessness, agitation, stomach upset, irritability 12 Steps to SSRI Treatment

10  Measure the symptoms › Pay special attention to suicidality  Provide comprehensive information › About disorder and treatment options  Provide family and child with SSRI info › Side effects & timelines to improvement  Start with small test dose of medication  Slowly increase dose  Take advantage of the placebo response 12 Steps to SSRI Treatment

11  Fluoxetine › Best level one evidence › Do not use alone › May increase…  Suicidal ideation ???  Self harm › Assessment of suicide risk ongoing Initiating Pharmacological Treatment

12 START LOW & GO SLOW Begin 5-10 mg/day for 1-2 wks (2.5-5 mg if significant anxiety symptoms) Liquid form: 2.5 – 5 mg/day; smaller increases Target dose 20 mg/day for min. 8 wks Expect continued improvement for a few months at same dose if initial response is positive Side Effects: If problematic cut increases back by 5 mg for 1 week and then add the extra 5 mg to dose. Discontinuation: Taper gradually over several months at low stress times Fluoxetine Treatment

13ItemNoneMildModerateSevere Headache Irritability/Anger Restlessness Diarrhea/Stomach upset Tiredness Sexual Problems Suicidal Thoughts Self Harm AttemptYes: No: If yes, describe: Was this a suicide attempt (attempt to die)? Yes: No: Other problems1. 2. Short Kutcher Chehil Side Effects Scale (sCKS) for SSRIs

14 Three important side effects to look for when initiating treatment with SSRI’s are…  Hypomania  Suicidal ideation  Suicidal behaviors Side Effects of SSRI’s

15  Rare side effect › Decreased sleep › Increase in activity  Idiosyncratic/inappropriate › Increase in motor behavior (including restlessness), verbal productivity and social intrusiveness  Discontinue medication  Urgently refer to mental health services  Family history of bipolar disorder Hypomania

16  May onset/exacerbate once medication is started but overall a substantial DECREASE >Stop medication immediately due to safety risk >Most common in first several months of medication ID stockxchng

17 Tool Base -line Da y 1 Day 5 Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8 KADSxxxxxx TeFAxxxxxx sCKSxxxxxxxxxxx Monitoring Treatment of Adolescent Major Depressive Disorder

18 Tool Base -line Day 1 Day 5 Wk 1 Wk 2 Wk 3 Wk 4 Wk 5 Wk 6 Wk 7 Wk 8 SCARE D xxxxx TeFA xxxxx sCKS xxxxxxxxxxx Monitoring Treatment of Anxiety Disorders o Children – SCARED & sCKS o Teens – SCARED, TeFA, sCKS

19 3 Possible Outcomes 3 Different Strategies ALWAYS CHECK ADHERENCE TO MEDICATION TREATMENT!!! 8 Weeks* of Dosage

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21  Not recommended for long term treatment*  While awaiting Fluoxetine, Sertraline or CBT response: › Clonazepam in small doses › A moderately long-acting benzodiazepine › 0.25 mg – 1.5 mg twice daily for 6 – 12 wks › Max 3.0 mg/day › Not usually for long term use; use an SSRI  Discontinue by tapering gradually › Decrease 0.25 mg/daily dose every week  Warn youth of risk of addiction & combining with alcohol * CAUTION Younger children more prone to disinhibition Clonazepam

22 Clonazepam INCREASE TO 0.5 mg BID for 3 days INCREASE TO 0.5 mg BID for 3 days No/ Little Response INCREASE TO 0.75 mg BID in 1 wk INCREASE TO 0.75 mg BID in 1 wk NO symptomatic improvement & min. side effects INCREASE TO 1 mg BID for 1 wk INCREASE TO 1 mg BID for 1 wk SOME symptomatic improvement & min. side effects